MEDICAL INFORMATION

MEDICAL INFORMATION
Patient's Name:

First NameLast Name
Date:

MonthDayYear
Height:
Weight:
Shoe Size:
Chief Foot / Ankle / Leg Problem (s)
How Painful is your Condition? 0 1 2 3 4 5 6 7 8 9 10 (0= no pain and 10= worst)
Onset and Duration of Problem:
Past Treatment:
Medications:
Allergies to Medications including tape:
Past Surgical History:
YesNo